Setup for an Open Reduction and Internal Fixation (ORIF) of the Tibia (Ivy Tech Community College, Indianapolis, IN)

CHAPTER 1

Hello, my name is Aaron Smith. I am an adjunct instructor for Ivy Tech Community College in Lawrence Township, Indiana. I'm also a certified surgical technologist for a local community hospital here in the city as well. I'm here to give you a basic setup and run through of an open reduction, internal fixation of the tibia, which is a very common surgical case done in orthopaedics. So, we'll get a rundown. I'll explain how I set up my table, how I set up my drapes, and just some basic instrumentation that you'll use for a case like this. Just keep in mind that, you know, as you work at different facilities, some of this will be somewhat different. Some facilities do require you to set up your tables a certain way. And so this is just, again, this is just a basic run through.

CHAPTER 2

Also, orthopaedics, specifically cases of this nature, one of the requirements is that you wear lead because there is a lot of x-ray that is done with these cases. And so lead is a requirement. So just know that you'll have to put on lead and a thyroid shield up under your gown and gloves and you'll have to have that on for the duration of the case.

CHAPTER 3

Okay, now first things first, once I get myself scrubbed in, my goal is to have my back table set up and ready to go so that I can count with my circulator and get that part of the case done before the patient gets in the room, okay? Again, you wanna be set up, counted, ideally have any meds that need to be passed to you, your fluids, your saline, and water, and your count, you want to have those things done before the patient gets in the room. Because once the patient gets in the room, your circulator's attention needs to be strictly on the patient. And so that's what our goal is. So when I open up my pack, first thing I'm gonna do is I'm going to make up in my mind where I'm going to place things because what we don't want to do is to keep shuffling things around on our back table. Everything has a home. It's our responsibility to get them to their home. And so I will towel out and place items where they need to be placed kind of simultaneously. And so again, on this side of the table, I'm gonna put my gown and my gloves and my towels, of course, and my drapes are also gonna go over here. And so I'm gonna do that, set my bowl on this side of the table. While I'm moving things around, I have a sterile basin for my throws as well. My throws meaning my suction, my Bovie, my light handles, et cetera, the things that are gonna get thrown off once my patient is draped. And so as I'm removing things, I'm placing them where they're going to be. So my drapes and my towels obviously are gonna go over here. That's where I've been placing things. And then my drapes, I'm gonna place my drapes on the right side of the table, but I'm going to do it in a very specific order. I'm going to do it in the opposite order of how they're gonna be thrown on the patient. So the last thing to go on the patient is this extremity drape. So that's the first thing that I'm gonna put down over here. And then before that is a stockinette and Coban. So my stockinette and Coban will go next. And before that are my split drapes. My split drapes, you have one that goes up and then one that comes down over the patient. And then the very first thing is going to be their three-quarter sheet or half sheet. That three-quarter sheet or half sheet is gonna go up under the patient's leg first as the first introduction into the sterile field. So I have those set up in that order. If your pack has the trash bags with it, you can place them. You can place any extra table cover that you have or Mayo covers that you have that are extra also up under those drapes if you're not gonna need them right away. With my trash bag, again, they have a pull tab on here. You can literally just peel that off, set that on your table. I don't know how some of you feel about reaching into this bag because of it being below the table level of sterility, which is obviously our waist. So if I put things in there, once it's in there, it's in there. I don't reach my hand down in there and go below table level because again, that's a gray area that we call it with sterility. So, place my trash bag here. Then from there, I'm gonna finish toweling out the rest of my table where I'm gonna be placing my trays. I am also gonna make my roll towel. Now, I know that everyone has their own unique style when it comes to roll towels. I have mine as well. I kind of make my rolls a little bit thinner and I kind of pull out as I'm rolling mine, and I'll give my roll towel a little bit more sturdiness. And once I get about halfway, I'll take my palms and I kind of roll it down like this. Do that a couple of times. Now we've got a good solid roll towel. Now, place my main tray here, which for a tibia fixation case, it'll probably be more of what's called a knee ankle set. It'll have instruments that are very specific to those anatomy portions of the body. So, I'll get my roll tile out, get that up here. I'm gonna place another towel on the side of the table where my working basin is. Get my sharps nice and ready. Again, as I'm taking things out, these are my light handle covers, those are going to be part of my throws.

CHAPTER 4

My next thing here is when it comes to passing medications to my field, I'm gonna place my medicine cups over here on my Mayo. Again, my circulator, when she's passing meds to the field, does not have an option to reach over my sterile field. So, to make it easier for everybody involved and minimize the risk of contamination, I place these right at the end of my Mayo to where she can administer those medications to my field and she's not passing over anything that's sterile. Anytime you can do that, I always recommend doing things that way. You wanna make it easy for your circulator to pass medications to your field, and it minimizes the risk of your field getting contaminated. And so we keep sterile consciousness at a very, very high level in regards to that.

CHAPTER 5

So, just a little sidebar here, there is a reason why in orthopaedics we double glove, okay? Protection. It's a second layer of protection. And I'm using myself as an example now because I got a hole in my under glove. I also have an outer glove on. So just because I got a hole in my indicator glove, I still have an outer glove on and so that layer of protection is still there so that I still have not contaminated anything. But me being the sterile-conscious person that I am what I would do ideally in this situation is, even though I see that, and even though I know I'm still protected, I would still have my circulator pull my glove off and pass me a new set of gloves to put on. Okay, again, you want to be and remain as sterile-conscious as possible. So again, just on a side note, I'm still good. My outer glove is still intact. This is why we double glove. Because had I not double gloved and that happened, then I would've ran a risk of having to break this entire thing down because it would've been contaminated. So again, that's why we double glove. Okay?

CHAPTER 6

Now, from here, I'm going to place my Bovie, my suction, my light handles, all gonna go in there, along with my scratch pad, which is also a countable item by the way, as well. And from this point, now I'm going to get with my circulator and let my circulator know that I am ready to count. So, I get my blades out. All right, and with that, we will have laps, one, two, three, four, and five. And then one, two, three, four, five of ten. So I have 10 laps. Ray-Tecs, I have one, two, three, four, five, six, seven, eight, nine, and ten. 10 Rays. Blades, I have one, two, and three. Cautery tips, I have one. And again, when I put my Bovie in here, I'm putting my Bovie in here with the tip up so that my circulator can see everything that I'm counting. So one Bovie tip. And then I have my one scratch pad as well. Needles, I have one, two, and three.

CHAPTER 7

Okay, so now our count is done. I want to go ahead and get fluids and my meds, saline and water. You know, I'll put sterile water in one part of my basin. I'll put the saline in another part of that basin. We all know that when it comes to fluids, you should always have sterile water on your field if for no other reason for fire risk. So we wanna make sure we have sterile water and saline and make sure that those are labeled appropriately. Some of your packs will have these premade labels that makes our life a lot easier to where you can literally just take the sticker and place it on there, take the sticker for saline and place it on your saline. Everybody's happy and we can move forward.

CHAPTER 8

Okay, now, once I've done that, I've gotten counted, from here on out now our circulator can focus her attention strictly on the patient, which is the way that it should be. And we can focus on whatever else we need to focus on as far as our setup goes. And so from here, now, I'm going to load my knife. So I'm going to take my knife handle here and I'm going to take my needle holder. All right, and I'm gonna take my 10 blade and load it on my #3 knife handle. Always important to have your knife loaded very early on in the process.

CHAPTER 9

Okay, I'm gonna place my drapes now in the order that they're gonna be draped to the patient. I'm gonna place those right on top of that bowl. So once my surgeon is draped, and once my assist is draped and we're ready to drape the patient, I'll wheel this entire basin right up to the patient. We can go one, two, three, four, five in that order. Keep everything nice and efficient.

CHAPTER 10

So with my meds, I'm gonna make sure that I label my medications as well. Same thing, we have these wonderful labels for that. For the medications that you're gonna be using. And so if you're lucky enough to have these, we're gonna also label our medications as well. And we're also going to draw up any medicine that we need to draw up out of those and place those in syringes if your surgeon wants to administer any local before he makes his incision. Again, they don't always do that. Some like to do local at the very beginning of the case. Some of them like to inject local at the end of the case. Some surgeons like to inject off the field before they even start the case. And so again, it's all about a preference thing, but if you have it on your field, label it, draw it up, and have it ready to go for your surgeon when he or she asks for it.

CHAPTER 11

Okay, now, I've got my drapes ready, I've got my gown and my gloves ready for my surgeon. So now I'm going to put on my Mayo here the instruments that I need for exposure, because again, that is the first part of our case once that incision is made is the exposure piece. And so for this case, we have both handheld and self-retaining retractors that we can use for this. So, we do have our Weity that we can place up there. We'll need a couple of pair of pickups with teeth. So we'll place both our Adsons with teeth and our Ferris-Smiths. And of course, you know, Ferris-Smith, Big Joe's, we also have Bonnie's, you know, they're all kind of in that same family. So again, depending on your facility and what you have, those are the things that you will use. I will also put some handheld retractors up there as well. So, we'll place a couple of Senn rakes. Sometimes your assist or your surgeon will take the atraumatic ends, place them on either side of the incision and open that up so that they can do more blunt dissecting. And that blunt dissecting is primarily done with a pair of Metzenbaum scissors. So, we'll place those up there as well. For any kind of debridement, a rongeur would be the appropriate tool for that. And again, depends on the size of your incision that you're working with. For a tibial fracture, primarily a smaller rongeur, you know, something like this one, which is a Fulton rongeur, would be more appropriate than something like this, which is a Leksell. This is probably more spine related when it comes to rongeurs, but you never know. So it's good to have just in case you need it. And then the other thing that I would place up there would be the Key elevator, which is a periosteal elevator. They will sometimes use that in the exposure piece as well.

CHAPTER 12

As a scrub, make sure that you drape your C-arm because as I stated earlier in the case, we're gonna use lead for this case. And so the C-arm will come up over the patient and it has to come up over the patient sterilely. And so we wanna make sure we drape it. And this is called a snap cover. And basically once you open this up, you're gonna invert it so that your hands are still covered. You're gonna come up, over, and down, again with your hands inside the entire time. That's just a very simple, basic way to drape your C-arm.

CHAPTER 13

So once you have that done, now we can come over here to our rep table. Your reps are your best friend. They will get you set up as far as what instrumentation you need out of their stuff. They'll let you know the steps that the surgeon is gonna take when he's doing the fixation. So, pay attention to your reps. That's, I can't stress enough how important that is. So, we are also going to use power. We use a drill. And in some cases, not necessarily this one, we would use a saw. But for this case, we are gonna use a power drill. And so our Stryker power set that we have here has the attachment for your drill here. And it is battery operated. One thing I do recommend, do not connect your battery until you are ready to do the drilling. These batteries, sometimes, even though they're supposed to be charged before they're sterilized, sometimes they're not. And even if they are, the battery life is not as long as you think it is, and so if you have this thing hooked up right at the beginning of the case, but then you're not gonna be using it for, you know, 30 or 45 minutes, then you're gonna run the risk that that battery life is not gonna be there. And that's the worst thing you want is for your battery to die out in the middle of a case. Okay, but you can attach your battery, give it a test, you know it's good. So, your power has a few attachments in here. It has what's called an AO quick connect. Basically slide that down, lock it in. There's also a Hudson and there is a chuck and key. Depending on what you're using will dictate which of these attachments that you're going to use. You will have a rep pan as well. Your rep pan will have your screwdrivers, your depth gauge, it'll have several things in there, one of which that you'll use very early are called bone clamps or reduction forceps. Again, when you have a fracture, before you can plate it, you have to reduce the fracture. And what I mean by reduce the fracture is if you have a piece of bone here and a piece of bone here that is supposed to go together, if there's a fracture in it, you have to reduce the space in between the fracture, okay? And that's what this bone forcep is for. You clamp one end to one end of the bone, the other part to the other end of the bone, squeeze those together, it reduces the fraction. It's one of the first things that they're gonna do before they start plating. So, you wanna make sure you have your bone forceps. And then from there it goes, drill, measure, tap, screw. That is a common orthopaedics order of operations: drill, measure, tap, screw. And so we wanna have those items out as well. And so for me, I have my drill, I have my measuring tool, my depth gauge, I have my tap, and then your screwdriver would be the last thing that you would have. We go in that order for a reason. Your drill is your initial hole. You're gonna drill your initial hole, you're gonna measure it with your depth gauge, surgeon may choose to tap, and what the tap does is it basically, it's like a starter thread for the screw that you're gonna use. And the screws that you have, you have both what are called fully-threaded screws, and then you have partially-threaded screws. This would be considered a fully-threaded screw. This would be considered a partially-threaded screw because there's a smooth part and then there's also the threaded part on there as well. Another name for those would be a cortical screw versus a cancellous screw. And that has a lot to do with the threading. The threading on your cortical screws is a lot more condensed, whereas with a cancellous screw, the threads are a lot more spread out because you're drilling through two different types of bone. Okay? So now we have that. You have your instrumentation out here. Plates will be determined by your surgeon, what kind of plates that you want. And so you'll have tubular plates, you'll have tibial plateau plates. There's several options, but this is where your rep comes in. And your rep will direct you on which ones, how they're gonna be used, or where they're gonna be placed.

CHAPTER 14

At this stage, you're set. You are ready to go. Your surgeon comes in, you gown them, you glove them, get the drapes thrown off, and then you are all set. And so that is a basic setup for your open reduction, internal fixation of a tibia. Again, there may be some variations with this based upon your facility, but that concludes what your basic setup would be.